Clinical Edits

The Texas Managed Medicaid STAR/CHIP formulary, including the Preferred Drug List and any clinical edits, is defined by the Texas Vendor Drug Program.

Texas Vendor Drug Program Clinical Edit Website: https://www.txvendordrug.com/formulary/prior-authorization/care-clinical-prior-authorization

Please click on the link(s) below to view the Texas Medicaid STAR and CHIP implemented clinical edits.

Click here for Prior Authorization information.

Type	Name		File Size
PDF File	Accolate Eff. Date: 08/28/2019	ACCOLATE, ZAFIRLUKAST	469 KB
PDF File	ADD_ADHD Eff. Date: 05/20/2020	ADDERALL, AMPHETAMINE, AMPHETAMINE/DEXTROAMPHET SALTS, DESOXYN, DEXMETHYLPHENIDATE, EVEKEO, FOCALIN, METHAMPHETAMINE, METHYLIN, METHYLPHENIDATE, PROCENTRA, RITALIN, ZENZEDI, ADZENYS, ADZENYS-ODT, AMPHETAMINE/DEXTROAMPHET SALTS ER, ADHASIA XR, APTENSIO XR, CONCERTA ER, COTEMPLA, DAYTRANA, DEXEDRINE, DEXMETHYLPHENIDATE, DYANAVEL, FOCALIN XR, METHYLPHENIDATE ER, METHYLPHENIDATE CD, MYDAYIS, QUILLICHEW, QUILLIVANT, RITALIN, VYVANSE, GUANFACINE, INTUNIV, STRATTERA, CLONIDINE	933 KB
PDF File	Agents for Gaucher’s Disease - HHSC Eff. Date: 7/15/2019	CERDELGA, CEREZYME, ELELYSO, MIGLUSTAT, VPRIV, ZAVESCA	410 KB
PDF File	Alinia - HHSC Eff. Date: 2/17/2021	ALINIA	813 KB
PDF File	Aliskiren - HHSC Eff. Date: 03/21/2019	TEKAMLO, TEKTURNA, AMTURNIDE, TEKTURNA HCT	1 MB
PDF File	Allergen Extracts - HHSC Eff. Date: 12/10/2019	ORALAIR	350 KB
PDF File	Amantadine Extended-Release Agents - HHSC Eff. Date: 01/27/2021	GOCOVRI ER, OSMOLEX ER	598 KB
PDF File	Antiemetics - HHSC Eff. Date: 3/21/2019	AKYNZEO, ANZEMET, APREPITANT, EMEND, GRANISETRON HCL, SANCUSO	291 KB
PDF File	Antipsychotics Eff. Date: 03/12/2021	ABILIFY, ABILIFY DISCMELT, ABILIFY MAINTENA, ABILIFY MYCITE, AMITRIPTYLINE/PERPHENAZINE, ARIPIPRAZOLE, ARISTADA ER, CAPLYTA, CHLORPROMAZINE, CLOZAPINE, CLOZAPINE ODT, CLOZARIL, FANAPT, FAZACLO, FLUPHENAZINE, GEODON, HALOPERIDOL, INVEGA ER, INVEGA SUSTENNA, INVEGA TRINZA, LATUDA, LOXAPINE, MOLINDONE HCL, OLANZAPINE, OLANZAPINE ODT, OLANZAPINE/FLUOXETINE, ORAP, PALIPERIDONE ER, PERPHENAZINE, PERSERIS ER, PIMOZIDE, QUETIAPINE , REXULTI, RISPERDAL , RISPERDAL CONSTA, RISPERDAL M-TAB, RISPERIDONE, SAPHRIS, SECUADO, SEROQUEL, SYMBYAX, THIORIDAZINE, THIOTHIXENE, TRIFLUOPERAZINE, VERSACLOZ, VRAYLAR, ZIPRASIDONE, ZYPREXA, ZYPREXA RELPREVV, ZYPREXA ZYDIS	650 KB
PDF File	Anxiolytics and Sedatives Hypnotics (ASHs) - HHSC Eff. Date: 2/01/2021	ALPRAZOLAM, XANAX, CHLORDIAZEPOXIDE, MEPROBAMATE, OXAZEPAM, DIAZEPAM, CLONAZEPAM, KLONOPIN, CLORAZEPATE, TRANXENE T, LORAZEPAM, TEMAZEPAM, TRIAZOLAM, ZOLPIDEM, ESTAZOLAM, RESTORIL, TEMAZEPAM, ESZOPICLONE, LUNESTA, SONATA, ZALEPLON, INTERMEZZO, ZOLPIDEM, AMBIEN, EDLUAR, BELSOMRA, BUTISOL SODIUM, FLURAZEPAM, HETLIOZ, ROZEREM, DAYVIGO	2 MB
PDF File	Arikayce HHSC Eff. Date: 4/26/2019	ARIKAYCE	218 KB
PDF File	Buprenorphine Agents – HHSC Eff. Date: 03/22/2019	BUNAVAIL, BUPRENORPHINE, BUPRENORPHINE-NALOXON, SUBOXONE, ZUBSOLV	809 KB
PDF File	Carisoprodol - HHSC Eff. Date: 05/23/2019	CARISOPRODOL-ASPIRIN, CARISOPRODOL COMPOUND, CARISOPRODOL CPD-CODEINE, CARISOPRODOL, SOMA	260 KB
PDF File	CGRP Antagonists Acute - HHSC Eff. Date 10/28/2020	NURTEC ODT, UBRELVY	934 KB
PDF File	CGRP Antagonists Chronic HHSC Eff. Date 08/29/2019	AIMOVIG, AJOVY, EMGALITY	314 KB
PDF File	CNS Stimulants - HHSC Eff. Date: 10/29/2019	ARMODAFINIL, MODAFINIL, NUVIGIL, PROVIGIL, SUNOSI	406 KB
PDF File	Contraceptives - CHIP ONLY Eff. Date: 10/22/2012		22 KB
PDF File	Contraceptives - Dell Children’s Health Plan Only Eff. Date: 12/09/2016		18 KB
PDF File	Cough/Cold Medications - HHSC Eff. Date: 03/10/2020	ALA-HIST, ALLFEN DM TAB, AP-HIST DM LIQ, APRODINE TAB, BENZONATATE, BROMFED DM CGH SYR, BROMPHENIR-PSEUDO-DM SYR, BROTAPP, CHEST CONG RELIEF, CHLD DELSYM, CHLD COLD & CGH DM ELIXI, CHLD MUCINEX, CHLD DAYCLEAR ALL CGH, CHLO TUSS LIQ, CGH DM, CGH SYR, DALLERGY, DECONEX DMX TAB, DECONEX IR TAB, DELSYM, DEXTROMETHORPHAN ER, DIMAPHEN, ED A-HIST, ED BRON GP LIQ, ED CHLORPED D PEDIATRIC DROPS, ENDACOF-DM LIQ, EX ACTION CGH SYR, GUAIFEN, GUAIFEN ER, GUAIFEN/PSE, HISTEX, IOPHEN, KIDKARE CGH & COLD LIQ, KID'S MUCINEX MINI-MELTS PACK, LODRANE D CAPSULE, LOHIST, LORTUSS, MAXIPHEN, M-END DMX LIQ, M-HIST DM LIQ, MUCINEX, MUCUS RELIEF, NASAL DECON SPRAY, NASOPEN PE LIQ, NINJACOF LIQ, NOHIST, NOSE DROPS, ORGAN-I, PEDIATRIC CGH-COLD LIQ, PHENYLEPHRINE-PYRILAMINE, POLY HIST, POLY-VENT, POLYTUSSIN, PROMETHAZINE, Q-TUSS, RESCON, RESPAIRE-30, ROBAFEN, RU-HIST D, RYMED, SILTUSS, SM NASAL SPRAY, SM TUSS DM, STAHIST AD, SUDOGEST SINUS & ALLERGY TAB, TUSS, VANACOF, VANATAB	438 KB
PDF File	COX-2 Inhibitors Eff. Date: 4/24/2020	CELEBREX, CELECOXIB, MELOXICAM, MOBIC	1020 KB
PDF File	Cystic Fibrosis Agents - HHSC Eff. Date: 01/20/2021	KALYDECO, ORKAMBI, SYMDEKO, TRIKAFTA	2 MB
PDF File	Cytokine and CAM Antagonists Eff. Date: 04/01/2021	ACTEMRA, CIMZIA, COSENTYX, ENBREL, HUMIRA, ILARIS, ILUMYA, KEVZARA, KINERET, OLUMIANT, ORENCIA, OTEZLA, RINVOQ, SILIQ, SIMPONI, SKYRIZI, STELARA, TALTZ, TREMFYA, XELJANZ	3 MB
PDF File	Desmopressin Eff. Date: 03/15/2021	DDAVP, DESMOPRESSIN ACETATE	1014 KB
PDF File	Dextromethorphan Overutilization - HHSC Eff. Date: 12/30/2019	ALA-HIST DM LIQ, AP-HIST DM LIQ, ALLFEN DM TAB, BROMFED DM CGH, BROMPHENIR-PSEUDO-DM SYR, BROTAPP DM LIQ, CHILD DELSYM, CHILD C&C DM ELIX, CHILD MUCINEX, DECONEX DMX TAB, DELSYM 30MG/5ML SUSP, DELSYM CGH+CHEST CNGST DM LQ, DEXTROMETHORPHAN ER 30MG/5ML, DIMAPHEN DM ELIX, ED-A-HIST DM LIQ, ED-A-HIST DM TAB, ENDACOF-DM LIQ, EXT ACTION CGH SYR, GUIAFEN-DM ER 1,200-60MG TAB, HISTEX-DM SYR, IOPHEN DM-NR LIQ, KIDKARE C&C LIQ, LOHIST-DM SYR, LORTUSS DM LIQ, M-END DMX LIQ, M-HIST DM, MAXIPHEN DM TAB, MUCINEX CGH MINI-MELT PACK, MUCINEX DM ER 600-30MG TAB, MUCINEX DM ER 1,200-60MG TAB, MUCINEX FAST-MAX CONG-CGH, MUCINEX FAST-MAX DM MAX LIQ, NOHIST-DM LIQ, PED C&C LIQ, POLY-HIST DM LIQ, POLY-VENT DM TAB, POLYTUSSUN DM, PROMETH-DM SYR, Q-TUSS DM SYR, RESCON-DM LIQ, ROBAFEN CF LIQ, ROBAFEN-DM, ROBAFEN CGH 15MG LIQGEL, ROBAFEN DM CGH-CHEST CONG SYR, RYNEX DM LIQ, SILTUSS DM CGH SYR, SILTUSS DM DAS LIQ, SM TUSS DM, TUSS DM, VANACOF DM LIQ, VANATAB DM CAP, VIRDEC DM DRP	220 KB
PDF File	Diacomit - HHSC 08/20/2020	DIACOMIT	585 KB
PDF File	Diclofenac - HHSC Eff. Date: 3/27/2019	DICLOFENAC GEL 3%, DICLOFENAC SOL 1.5%, PENNSAID SOL 2%	300 KB
PDF File	Dopamine Agonists - HHSC Eff. Date: 02/22/2021	APOKYN, KYNMOBI	606 KB
PDF File	Doxylamine/Pyridoxine - HHSC Eff. Date: 10/29/2019	BONJESTA ER, DICLEGIS DR	254 KB
PDF File	DPP4 Inhibitors - HHSC Eff. Date: 3/27/2019	ALOGLIPTIN, ALOGLIPTIN-METFORMIN, ALOGLIPTIN-PIOGLIT, GLYXAMBI, JANUMET, JANUMET XR, JANUVIA , JENTADUETO, JENTADUETO XR , KAZANO, KOMBIGLYZE XR , NESINA, ONGLYZA , OSENI , QTERN , STEGLUJAN, TRADJENTA	314 KB
PDF File	Drug Regimen Optimization - HHSC Eff. Date: 11/22/2019	ALTACE, DIOVAN, RAMIPRIL	283 KB
PDF File	Dupixent - HHSC Eff. Date: 03/03/2021	DUPIXENT	3 MB
PDF File	Emflaza - HHSC Eff. Date: 7/03/2019	EMFLAZA	306 KB
PDF File	Enzymes - HHSC Eff. Date: 09/11/2019	ALDURAZYME, ADAGEN, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, RECOVI, VIMIZIM	366 KB
PDF File	Epidiolex HHSC Eff. Date: 08/20/2020	EPIDIOLEX	597 KB
PDF File	Erythropoiesis-Stimulating Agents - HHSC Eff. Date: 10/07/2020	ARANESP, EPOGEN, PROCRIT, RETACRIT	1 MB
PDF File	Evrysdi - HHSC 01/22/2021	EVRYSDI	771 KB
PDF File	Fentanyl Agents - HHSC Eff. Date: 3/28/2019	ABSTRAL, ACTIQ, DURAGESIC, FENTANYL, FENTORA, LAZANDA, SUBSYS	2 MB
PDF File	Flexeril/Amrix (Cyclobenzaprine) Eff. Date: 5/10/2019	AMRIX, CYCLOBENZAPRINE, FEXMID	475 KB
PDF File	GI Motility Agents - HHSC Eff. Date: 7/30/2019	AMITIZA, LINZESS, ALOSETRON HCL, LOTRONEX, MOVANTIK, MOTEGRITY, RELISTOR, SYMPROIC, TRULANCE, VIBERZI	777 KB
PDF File	GLP1 Receptor Agonist HHSC Eff. Date: 7/15/2020	ADLYXIN, BYDUREON, BYETTA, OZEMPIC, RYBELSUS, SOLIQUA, TRULICITY, VICTOZA, XULTOPHY	354 KB
PDF File	Growth Hormone - HHSC Eff. Date: 02/20/2020	GENOTROPIN, HUMATROPE, NORDITROPIN, NORDIFLEX, NORDITROPIN FLEXPRO, NUTROPIN AQ, OMNITROPE, SAIZEN, TEV-TROPIN, SEROSTIM, ZORBTIVE	882 KB
PDF File	Hemady - HHSC Eff. Date: 01/27/2021	HEMADY	622 KB
PDF File	Hepatitis C - Refill - HHSC Eff. Date: 03/2018	EPCLUSA, DAKLINZA, HARVONI, MAVYRET, OLYSIO, SOVALDI, TECHNIVIE, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER	77 KB
PDF File	Hepatitis C Initial Request - HHSC Eff. Date: 03/2021	EPCLUSA, DAKLINZA, HARVONI, MAVYRET, OLYSIO, SOVALDI, TECHNIVIE, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER	97 KB
PDF File	Hereditary Angioedema (HAE) - HHSC Eff. Date: 07/15/2019	BERINERT, CINRYZE, FIRAZYR, HAEGARDA, KALBITOR, RUCONEST, TAKHZYRO	208 KB
PDF File	HP Acthar - HHSC Eff. Date: 7/24/2020	HP ACTHAR GEL	405 KB
PDF File	Imiquimod - HHSC Eff. Date: 3/29/2019	ALDARA, IMIQUIMOD, ZYCLARA	219 KB
PDF File	Increlex - HHSC Eff. Date: 3/29/2019	INCRELEX	569 KB
PDF File	Inhaled Antibiotics HHSC Eff. Date: 02/13/2020	BETHKIS, CAYSTON, KITABIS PAK , TOBI, TOBRAMYCIN	260 KB
PDF File	Ketorolac (Toradol) - HHSC Eff. Date: 03/29/2019	KETOROLAC	382 KB
PDF File	Keveyis - HHSC Eff. Date: 3/29/2019	KEVEYIS	275 KB
PDF File	Lidoderm Patches - HHSC Eff. Date: 7/15/2019	LIDOCAINE, LIDODERM, ZTLIDO	260 KB
PDF File	Lovaza - HHSC Eff. Date:: 3/29/2019	LOVAZA, VASCEPA	267 KB
PDF File	Makena (CFHP,Dell,Driscoll,ElPaso,FC,Parklnd, S&W) Eff. Date: 10/28/2020	MAKENA	45 KB
PDF File	Makena (CHC, CCHP, TCHP) Eff. Date: 10/28/2020	MAKENA	47 KB
PDF File	Monoclonal Antibody Agents for Asthma - HHSC Eff. Date: 2/01/2021	FASENRA, NUCALA	1 MB
PDF File	Neurontin (Gabapentin) HHSC Eff. Date: 3/29/2019	GABAPENTIN, GRALISE, HORIZANT, NEURONTIN	673 KB
PDF File	Nuplazid - HHSC Eff. Date: 3/29/2019	NUPLAZID	419 KB
PDF File	Opioid Policy Criteria - HHSC 07/20/2020	APAP-CAFF-DIHYDROCOD, APAP-COD, ACTIQ, APADAZ, ASCOMP/COD, BELBUCA, BELLADONNA-OPIUM, BUPRENORPHINE, BUTALB-APAP-CAFF-COD, BUTALB-CAFF-APAP-COD, BUTALBITAL COMP-COD, BUTORPHANOL, BUTRANS, CARISOPRODOL CPD-COD, COD-GUAIFEN, COD SULFATE, DEMEROL, DILAUDID, DOLOPHINE HCL, DURAGESIC, DVORAH, EMBEDA ER, ENDOCET, FENTANYL, FENTORA, FIORINAL-COD, GUAIFEN-COD , GUAIATUSSIN AC, HYDROCODON-APAP, HYDROCODONE BT-IBU, HYDROCODONE-CHLORPHEN ER, HYDROCOD-HOMATROPINE, HYDROCODONE BT-IBU, HYDROCODONE-IBU , HYDROMET, HYDROMORPHONE, HYDROMORPHONE HCL ER, HYSINGLA ER, KADIAN ER, LAZANDA NASAL SPRAY, LEVORPHANOL, LORCET, MEPERIDINE, METHADONE, METHADOSE, MORPHABOND ER, MORPHINE, MS CONTIN, NALBUPHINE, NALOCET, NINJACOF-XG, NORCO, NUCYNTA, NUCYNTA ER, OPIUM, OXYCODONE, OXYCODONE-APAP, OXYCODONE-ASA , OXYCODONE-IBU, OXYCONTIN, OXYMORPHONE HCL, OXYMORPHONE HCL ER, PENTAZOCINE-NALOXONE, PERCOCET, PROMETHAZINE-COD, ROXICODONE, SUBSYS SPRAY, TRAMADO, TYLENOL COD, ULTRACET, ULTRAM, VICODIN, VIRTUSSIN, XTAMPZA ER	1005 KB
PDF File	Opthalmic Immunomodulators - HHSC Eff. Date: 6/30/2020	CEQUA, RESTASIS MULTIDOSE, RESTASIS EYE EMULSION, XIIDRA	267 KB
PDF File	Oriahnn - HHSC Eff. Date: 10/28/2020	ORIAHNN	884 KB
PDF File	Orilissa - HHSC Eff. Date: 3/29/2019	ORILISSA	403 KB
PDF File	Oxervate - HHSC 07/24/2020	OXERVATE	270 KB
PDF File	Oxycodone Extended Release - HHSC Eff. Date: 3/29/2019	OXYCONTIN, OXYCODONE HCL ER, XTAMPZA ER	2 MB
PDF File	Palforzia - HHSC 08/24/2020	PALFORZIA	687 KB
PDF File	PCSK9 Inhibitors - HHSC Eff. Date: 04/06/2020	PRALUENT, REPATHA	543 KB
PDF File	PDE5 - Inhibitors - HHSC Eff. Date: 11/08/2019	ADCIRCA, REVATIO, SILDENAFIL, TADALAFIL	354 KB
PDF File	Phenergan (Promethazine) - HHSC Eff. Date: 3/29/2019	PHENADOZ, PHENERGAN, PROMETHAZINE, PROMETHAZINE-CODEINE SYRUP, PROMETHEGAN	207 KB
PDF File	Phosphate Binders - HHSC Eff. Date:01/30/2020	AURYXIA, CALCIUM ACETATE, ELIPHOS, FOSRENOL, LANTHANUM CARB, PHOSLYRA SOL, VELPHORO	231 KB
PDF File	Propylthiouracil - HHSC Eff. Date: 3/29/2019	PROPYLTHIOURACIL	399 KB
PDF File	Ranexa - HHSC Eff. Date: 3/29/2019	RANEXA	374 KB
PDF File	Savella - HHSC Eff. Date: 3/29/2019	SAVELLA	669 KB
PDF File	SGLT2 Inhibitor Agents HHSC Eff. Date: 5/01/2019	FARXIGA, INVOKAMET, INVOKAMET XR, INVOKANA, JARDIANCE, SEGLUROMET, STEGLATRO, SYNJARDY, SYNJARDY XR, XIGDUO XR	265 KB
PDF File	Sickle Cell Agents - HHSC Eff. Date: 01/30/2020	OXBRYTA	385 KB
PDF File	Symlin - HHSC Eff. Date: 3/29/2019	SYMLIN, SYMLINPEN	250 KB
PDF File	Synagis - HHSC Eff. 08/11/2020	SYNAGIS 50 MG/0.5 ML VIAL, SYNAGIS 100 MG/1 ML VIAL	774 KB
PDF File	Thiazolidinediones - HHSC Eff. Date: 11/11/2020	ACTOPLUS MET, ACTOPLUS MET XR, PIOGLITAZONE-METFORMIN, ACTOS, DUETACT, PIOGLITAZONE HCL, PIOGLITAZONE-GLIMEPIRIDE, AVANDIA	977 KB
PDF File	Topical Acne Agents Eff. Date: 4/05/2021	BENZACLIN GEL, CLINDAMY/BEN GEL, ERY/BENZOYL GEL	641 KB
PDF File	Topical Immunomodulators Elidel Protopic Eucrisa Eff. Date: 8/13/2020	ELIDEL, PROTOPIC, TACROLIMUS, EUCRISA	863 KB
PDF File	Topical Retinoids Eff. Date: 12/01/2020	ADAPALENE, ADAPALENE-BENZYL PEROX, AKIEF, ALTRENO LOTION, ATRALIN, AVITA, CLINDA-TRETINOIN, DIFFERIN, EPIDUO, EPIDUO FORTE, FABIOR, TAZAROTENE, TAZORAC, TRETINOIN, TRETINOIN GEL MICRO, ZIANA GEL	352 KB
PDF File	Transthyretin Agents - HHSC Eff. Date: 04/24/2020	TEGSEDI, VYNDAMAX, VYNDAQEL	288 KB
PDF File	Tyvaso Starter Kit Eff. Date: 07/06/2012	TYVASO	21 KB
PDF File	Urea Cycle Disorder HHSC Eff. Date: 4/26/2019	BUPHENYL, CARBAGLU, RAVICTI, SODIUM PHENYLBUTYRATE	169 KB
PDF File	VMAT2 - HHSC Eff. Date: 06/24/2020	AUSTEDO, INGREZZA, XENAZINE	533 KB
PDF File	Wakix - HHSC Eff. Date: 10/28/2020	WAKIX	660 KB
PDF File	Xenical Eff. Date: 09/21/2018	XENICAL	44 KB
PDF File	Xifaxan (Rifaximin) - HHSC Eff. Date: 3/29/2019	XIFAXAN	288 KB
PDF File	Xyrem - HHSC Eff. Date: 10/28/2020	XYREM, XYWAV	657 KB
PDF File	Zelboraf - HHSC Eff. Date: 3/29/2019	ZELBORAF	290 KB
PDF File	Zyflo Eff. Date: 08/28/2019	ZYFLO	483 KB